Youth Parental Consent Form and Liability Release

Student's Name *

Student's Nickname

Date of Birth *

Current Grade *

Student's Address *

Parent(s)/Guardian(s) and Other Contacts

Parent/Guardian Name *

Parent/Guardian Email *

2nd Parent/Guardian Email

Home Phone *

Work Phone

Parent/Guardian Cell Phone *

2nd Parent/Guardian Cell Phone

Non-parent Emergency Contact #1 *

Emergency Contact 1 Primary Relationship *

Emergency Contact 1 Primary Phone *

Non-parent Emergency Contact #2 *

Emergency Contact 2 Primary Relationship *

Emergency Contact 2 Primary Phone

Medical/Health/Insurance Care Information

Student's Doctor Name *

Doctor Address

Doctor Phone Number *

After Hours Phone Number *

Telephone Number *

Medications *

Allergies *

Immunizations *

Special Conditions *

Schedule & Instructions Rules and Habits

Meals

Snacks

Other